SME Annual Meeting
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ASSESSING THE QUALITY OF INCIDENT INVESTIGATIONS AND ITS EFFECT ON SAFETY PERFORMANCE: A STUDY OF THE
GHANAIAN MINING INDUSTRY
E. Stemn, Univ. of Queensland, Brisbane, QLD, Australia
ABSTRACT
Incident investigation is of utmost importance in most high-risk
industries. This study was undertaken to study the content of past
investigation reports to determine the effectiveness of the incident
investigations. The study uses a semi-quantitative method to assess
the effectiveness of incident investigations in the Ghanaian mining
industry by evaluating the quality of past investigation reports. The
assessment tool consists of 5 elements with several indicators and
rating scales for assessing the quality of an investigation report as a
measure of the effectiveness of the investigation. The method was
applied to 304 investigation reports of 3 Ghanaian large-scale gold
mines, and the results correlated with incidence rates of the mines to
determine if any relationship existed. The results showed that the
mines differ significantly in the quality of their investigation reports,
suggesting differences in the effectiveness of their investigations. In
addition, the incidence rates of the mines negatively correlated with
some elements of the assessment tool. In general, the method was
found useful and revealed areas where improvement is needed.
Keyword: investigation reports; incidence rate; causal factors;
corrective measures
INTRODUCTION
The importance of learning from incidents is well documented in
the literature. For instance, some scholars regard learning from
incidents as important for improving safety [1,2]. Thus, many
organisations spend considerable resources in identifying lessons from
incidents and subsequently on the process of improvement that follows
the identification of lessons. It is therefore important for such
organisations to determine the effectiveness of their learning from
incidents processes, in order to identify specific areas where
improvements are needed, so that interventions can be as specific as
possible.
The learning from incidents process models the plan-act-check-do
approach of management systems, often consisting of four major
stages, namely; data collection and incident analysis, planning
interventions, implementing interventions and follow-ups and
evaluation [3,2]. The investigating and analysis of incidents have been
regarded as one of the vital stages of the learning process since it is
the stage where lessons are identified [3,2,4]. It has also been noted
elsewhere in the literature that results of the previous stage of the
learning process are important for the next stage [3]. For example,
ineffective incident analyses could result in the planning of ineffective
remedial measures. One of the primary aims of incident investigations
is to identify lessons from previous incidents which when implemented
can prevent future recurrences or minimise the effects of future
incidents. There is thus the need for organisations to assess the quality
of their investigations periodically since it is one of the means they
adopt to improve safety and the quality of remedial measures to some
extent depends on the effectiveness of the investigations. Although
previous studies [5,2] have assessed the effectiveness of the learning
process, and some aspects of the learning process, such as incidents
reporting, there is less focus on the effectiveness of incident
investigations. The research described in this paper was therefore
conducted to contribute to this gap, focusing more closely on incident
investigation reports.
1 Copyright © 2019 by SME
Preprint 19-003
In this paper, the term ‘incidents’ is used more broadly and refers
to undesirable events which affect safety, including those with actual
consequence and without actual consequence but with a potential to
do so. Also, the quality of an organisation’s investigation reports is
used as a measure of its safety culture and the effectiveness of its
investigation. This is based on the assumption that if an organisation is
committed to safety, it must reflect in how incidents are investigated. In
a matured culture, investigators have the courage and management
support to write about all causal factors that contribute to an incident
and this must reflect in investigation reports. The nature of the
recommendations must not only be limited to frontline human actions
but ought to be broad addressing technical and organisational related
issues as well. The paper first describes the method for assessing the
quality of investigation reports, followed by results of applying the
method to investigation reports from 3 mines to indicate the usability
and usefulness of the method.
METHOD
Adapting a method for assessing the quality of accident
investigations
The assessment method described here was partly adapted from
Jacobsson et al. [2] and Itoh et al. [5], and adding elements specific to
incident investigation reports collected from 6 large-scale Ghanaian
mines. The method consists of three components (Table 1, see
Appendix), namely,
• elements,
• indicators of each element and
• a rating scale for assessing the effectiveness of each
element based on the indicators.
The elements are various components of an investigation report,
and five elements were identified after reading through 450
investigation reports from six mines in Ghana. The elements, in turn,
contain several indicators that should be covered in an investigation
report. To be able to analyse an incident to determine what the causes
were and recommend measures for preventing future events, a good
description of the incident with relevant data is a prerequisite.
Therefore, as a minimum, an investigation report should contain
information on the incident itself, the circumstance surrounding the
incident, the causes of the incidents and recommendation of measures
for preventing future events. Thus, the elements of the assessment
tool are not exhaustive but rather a minimum requirement. The first
element general information focuses on characteristics of victims,
incident, equipment involved and those conducting the investigation.
The second, incident description consists of a detailed description of
the incident and the circumstances surrounding it. The third, time-band
description focuses on details of the sequence of event leading up to
and when the incident was resolved. The fourth and fifth elements
respectively concern the quality of causal factors identified from the
incident analysis and the corrective measures proposed following the
identified causes.
In order to assess and express the quality of investigation for the
various elements numerically (based on the content of investigation
reports), a rating scale was adapted from Jacobsson et al. [2]. To
assess the quality of investigation as objective as possible, the
different indicators for each element were described in a semi-
quantitative way on a scale of 1 to 10, divided into four quality levels as
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Feb. 24 - 27, 2018, Denver, CO

shown in Table 1. In using the scale, the assessor compares the Apart from elements E1 and E2 that showed no significant differences
information in the actual investigation report with the description in the in their mean scores, there were statistically significant differences in
scale, and the level best matching the actual description is selected [2]. the mean scores of the mines for the rest of the elements and the
After assessing each element, a mean value can be computed to overall quality of investigation. Post-hoc testing (Tukey HSD) showed
determine the overall quality of an investigation report as a measure of specific mine pairs with statistically significant differences in their
the effectiveness of the investigation. quality of investigation scores. For instance, for the overall quality of
investigation, mines pair AB and BC had statistically significant
Applying the assessment tool differences in their mean score, whereas, no significant difference was
The assessment tool was applied to 304 investigation reports of 3 found between Mines A and C. The mean scores of A (5.08 ± 1.45)
large-scale gold mines in Ghana. Table 2 shows characteristics of the and C (5.00 ± 0.98) was significantly higher than that of B 4.48 ± 1.05).
mines together with the number of reports. All the mines have a formal
process for managing incidents described in several documents. Table 4. One-way ANOVA of quality of investigation score (significant
Statistical tests were used to determine whether significant differences at p < 0.05).
existed in the quality of investigation among the 3 mines. Element name F(2, 301) Significant
E1. General information 1.02 0.360
Table 2. Attributes of the mines and the number of reports analysed
E2. Incident description 4.75 0.010
(2012-2016).
E3. Time-band description 48.56 0.000
Mine Type Operations Employees Reports E4. Causal factors 13.27 0.000
Part of a major multi- E5. Corrective measures 19.18 0.000
A Open-cast 1872 108
national corporation Overall quality of investigation 7.58 0.001
Part of a major multi-
B Open-cast 4892 104
national corporation Incidence rates as a measure of safety performance
Foreign-owned national Open-cast & The incidence rates of the mines differed from each other. Mine A
C 1603 92
with multiple sites underground had the lowest rate, followed by Mine C, with Mine B having the
highest incidence rate (Table 3). Again, one-way ANOVA (F(2, 177) =
Predictive validity of the assessment tool 29.53, p < 0.05) showed statistically significant difference in the mean
The predictive validity of the assessment tool was examined incidence rates of the mines. Tukey HSD post hoc test showed that
through correlation analysis. The quality of investigation scores for the Mine A’s (0.12 ± 0.11) incidence rate was statistically significantly
mines was correlated with the mine’s incidence rates. First, the lower than that of B (0.22 ± 0.13) and C (0.26 ± 0.05). However, there
monthly incidence rates of the mines were calculated using the was no statistically significant difference between the incidence rates
Australian Standard [6] for workplace injury and disease recording. The of Mines B and C.
incidence rates per one hundred workers were used as a measure of
the safety performance of the mines. The incidents used were the total Predictive validity of the assessment tools
reportable injuries [7]. The 5-year (2012-2016) incidence rate for each The Pearson’s correlation coefficients in Table 5 show that all the
mine was computed. Secondly, the means of the quality of elements of the quality of investigation assessment tool correlated
investigation scores of each of the 5 elements for each mine were negatively with the incidence rate expect element 2, incident
computed. These means were then correlated with the 5-year description, which had a positive correlation. However, it is only the
incidence rate of each mine through Pearson’s correlation. correlations of elements E4 (causal factors) and E5 (corrective
measures) that were found to be statistically significant, with the
RESULTS remaining elements being non-significant. Element E4, causal factor,
Quality of investigation had the highest correlation coefficient of -0.99 at p = 0.015. A
The means of the quality of investigation scores and the 5-year scatterplot (Fig. 1) of the incidence rates and the quality of
incident rates of all 3 mines are shown in Table 3. Some general investigation scores shows that Mine A with the highest quality of
observation can be made from the result. For most of the elements, the investigation score had the lowest incidence rate, whiles Mine B with
quality of investigation was at best “good” for the mines, except for the the highest incidence rate had the lowest quality of investigation score.
elements causal factors and corrective measures, which were “fair” for Table 5. Pearson’s correlation (r) between incidence rates and safety
Mines B, and C. Mine A had the highest scores for most of the culture maturity scores (N = 3, significant at p < 0.05).
elements than the other mines, remarkably for the elements causal Element name Mean SD r p-value
factors and corrective measures. Mine B trails in most of the elements.
E1. General information 6.02 0.1 -0.85 0.153
Across the mines and for the whole cohort, general information (E1)
E2. Incident description 5.66 0.26 0.91 0.090
and incident description (E2) appear to be the reasonably good
E3. Time-band description 4.52 1.03 -0.19 0.809
elements, whereas the important elements causal factors (E4) and
E4. Causal factors 4.39 0.52 -0.99 0.015
corrective measures (E5) seem to be the weakest. Consistently across
E5. Corrective measures 3.57 0.54 -0.97 0.026
the mines, the scores of the causal factors element exceeded that of
Overall quality of investigation 4.85 0.28 -0.79 0.210
corrective measures. This indicates that there were several instances
where causal factors identified were more broadly including aspects of
DISCUSSION
operator errors, workplace conditions and organisational factors.
However, in addressing these causal factors, a narrow view was In this research, a method for assessing the effectiveness of
adopted, focusing more on the proximate causes. incident investigation is presented and subsequently tested in real
case studies. Again, the predictive validity of the method is tested
Table 3. Mean values of quality of investigation scores and incidence
through correlation analysis. The research uses the quality of an
rates.
organisation’s incident investigation reports as a measure of the
E Incidence
Mine E1 E2 E3 E4 E5 effectiveness of its investigation. This is based on the assumption that
average rate
the effectiveness of an organisation’s incident investigation should
A 6.15 5.30 4.46 5.12 4.35 5.08 0.12 reflect in its investigation reports since the reports are the means of
B 5.98 5.81 3.37 3.96 3.17 4.48 0.26 communicating the investigation outcomes to management and
C 5.91 5.91 5.89 4.11 3.25 5.00 0.22 workers. The method was found useful in assessing past investigation
Whole reports, presenting some interesting results. However, a number of
6.02 5.66 4.52 4.39 3.57 4.85 0.19
cohort limitation should be noted in interpreting the results. First is the
subjective nature of the rating scare. Other opinions may exist about
One-way analysis of variance (ANOVA) shows that some of the appropriate rating scale, although the rate was found useful, yielding
quality of investigation elements differentiated between the mines and valuable results. It is therefore recommended that to strengthen the
the mines have different levels of investigating incidents (Table 4). objectivity of the rating scale, future research should focus on testing
2 Copyright © 2019 by SME

the validity and reliability of the method proposed here. The second
limitation is the sample size; the method was applied to 304
investigation reports across three mines. Results may therefore not
representing what is happening in the industry. A larger sample size
across several mines would be of great value to future research in
determining the effectiveness of investigation across the industry.
0.28
Overall quality of investigation score
0.26 B This research used a semi-quantitative method to assess the
0.24
0.22
0.20
0.18
0.16
0.14
0.12
0.10
4.4 4.5 4.6 4.7
incidence rate
Figure 1. Scatterplot of incidence rates and quality of investigation
scores.
In view of these limitations, the study presents some interesting
insights. Across all the mines, the general information element scored
highest, while causal factors and corrective measures scored the
lowest. This indicates that across the mines, there is a focus on
describing an incident scenario and identifying those involved in an
incident. However, when it comes to the most important part of
identifying the causes of an incident and proposing solutions, there is
less focus. The causes often identified had a local view, focusing on
the proximate causes. Again the result further suggests that, even
when distal causes are identified, the solutions proposed remain
shallow, addressing mostly the immediate causes, leaving the distal
causes unattended to.
There were significant differences between the mines regarding
the quality of their incident investigations, particularly in terms of causal
factor identified and corrective measures recommended. The score of
Mine A for the elements causal factors and corrective measures was
significantly higher than that of Mine B and C. Mine A appears to
identify and address distal causes more often than B and C. This
indicates that identifying and addressing distal causes is increasingly
being acknowledged in some mines than others although they may
have similar characteristics.
The results further showed a strong association between the
quality of investigation scores and the safety performance of the
mines. There were strong negative relationships between the
incidence rates of the mines and the scores of most elements of the
quality of investigation assessment tool, though not all were statistically
significant. The elements causal factors and corrective measures had
the strongest and significant negative relationship with the safety
performance of the mines. This suggests that the nature of causes
identified and corrective measures proposed from incident
investigations could be predictors of the safety performance of an
organisation. It further indicates that the mines should begin to
concentrate on the nature of causes they identify during incident
investigations and the extent to which the causes are addressed. Thus,
identifying and subsequently addressing high-level blunt-end causes
when investigating an incident is important to improve the safety
SME Annual Meeting
Feb. 24 - 27, 2018, Denver, CO
performance of an organisation [8]. In addition, the mine (A) that had
the highest quality of investigation score had the lowest incidence rate,
and the mine (B) that had the lowest quality of investigation score had
the highest incidence rate. However, further investigation and testing is
strongly recommended to determine the usefulness and applicability of
the method in a wide range of mines and industries.
CONCLUSIONS
effectiveness of incident investigations in three Ghanaian mines by
evaluating the quality of past investigation reports. Results indicated
that the mines emphasised more on describing an incident and those
C
that were involved with limited focus on the analysis of incidents to
identify causes and recommend solutions. There was focus on the
sharp-end causes compared to high-level blunt-end causes. In
addition, the quality of investigation scores correlated negatively with
the incidence rates, indicating that the quality of an organisation’s
incident investigation could be a predictor of its safety performance.
Thus, for organisations seeking to improve their safety performance,
there must be a deep focus on how incidents are investigated,
A particularly on the nature of causal factors identified and corrective
measures proposed.
4.8 4.9 5 5.1 5.2
ACKNOWLEDGEMENTS
We acknowledge the mines whose resource and data was
invaluable to the success of the research. Eric Stemn is a recipient of
an Australian Government Research Training Program (RTP)
Scholarship and UQ Centennial Scholarship at The University of
Queensland, Australia.
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safety/health-and-safety-performance-indicators. Accessed
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Accidents. Ashgate, Aldershot, Hants, England.
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APPENDIX
Table 1. Tool for assessing the quality incident investigation.
Element Indicators Quality (effectiveness) levels

1-2 (Poor) 3-4 (Fair) 4-7 (Good) 8-10 (Excellent)

Information about victims (e.g. name, age, Covers a few of the most Covers the most Covers all types of the Covers all indicators
General information

gender, work experience, department, job relevant indicators relevant indicators but relevant indicators but that are relevant and
title) date of incident, shift/time of incident, not well organised some indicators not in would add to the
date/time incident was reported, place of details usefulness of the
(E1)

incident, immediate action taken, information report in details

on who reported and who investigated (at
least the lead investigator) the incident.

What happened, type/class of incident, Missing relevant information Only the most obvious Almost all the relevant Covers all indicators in
Incident description

activity at the time of incident, damage to and facts on most of the information is indicators are full details, making
mining operation and mine equipment, indicators provided, making it provided, however useful and
condition of workplace, body part injured, hard to undertake some are not covered comprehensive
(E2)

actions taken after the incident, work comprehensive in detail, requiring analysis possible
environment, including the work-site, analysis of the incident additional information
operations, systems, work procedures

The sequence of events leading up to and Covers a few of the Covers the most Covers almost all the All indicators are
including the incident and when the incident indicators, mostly relevant indicators, relevant indicators, but covered in details,
Time-band of

was resolved. This includes information description of the mostly the pre- some not covered in making useful and
description

about past events (long before the incident), occurrence of the accidents accident and accident detail, requiring compressive analysis
(E3)

pre-incident (just before the incident), stage, however not additional information possible
incident (when the accident occurred), post- well organised
incident (immediately after the accident) and
future events (situation to be expected).

A measure of the quality of the causes Only identifies direct causes, Deals with both Covers both direct and All indicators are
determined. It should include various and usually operator errors or operator error and underlying causes and covered and in details,
Causal factors

multiple causal factors, both at the sharp-end some technical failures, a technical failures more begins to include making in-depth
and the blunt-end alike - personal very local view broadly and some aspect of workplace analysis possible
(E4)

shortcomings, (individual/team actions) management and design, work methods,

technical deficiencies, workplace design and organisational aspect organisational factors
work methods considerations, management
and organisation aspect, failed/absent
controls
A measure of the quality corrective measures Shallow control measures, Control measures Well-developed control Includes all indicators
proposed. It consist of a list of the actions to such as changes to deeper than the measures based on of the previous level
be taken (including technical and procedures, and few previous level, the causes identified with additional actions
Corrective measures

administrative controls, human-centred technical changes. including some aspect (with timeline and on a higher
actions and changes in organisational policy, Corrective actions aimed at of procedures, responsible persons). organisational level
believes, norms and culture), identify preventing the same incident training, technical Actions address such as management
(E5)

responsible persons to implement the actions from happening at the same changes, etc., but underlying causes, systems and safety
and specifies the timeframe of the actions. place mostly rather local workplace design, culture. Actions are
view work methods broad, on a site and/or
considerations. company level

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